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1 Texas Department of Aging and Disability Services Approved Diagnostic Codes for Persons with Related Conditions The following diagnostic codes are based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), 2006, and are recognized by the Department of Aging and Disability Services (DADS) as conditions which may qualify an individual as having a related condition as described in federal and state law. In accordance with the Code of Federal Regulations, Title 42, , a related condition is a severe and chronic disability that: (A) is attributed to: i. cerebral palsy or epilepsy; or ii. any other condition, other than mental illness, found to be closely related to mental retardation because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with mental retardation, and requires treatment or services similar to those required for individuals with mental retardation; (B) is manifested before the individual reaches age 22; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in at least three of the following areas of major life activity: i. self-care; ii. understanding and use of language; iii. learning; iv. mobility; v. self-direction; and vi. capacity for independent living. A primary diagnosis by a licensed physician (or designee as defined in program rules) of a related condition may be required to meet eligibility for the following Medicaid programs: Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), Texas Home Living (TxHmL), and Deaf Blind with Multiple Disabilities (DBMD). Complete information regarding eligibility is described in the rules governing each program. July 2015 Page 1

6 6 with loss of consciousness of unspecified duration 9 with concussion, unspecified Fracture of Skull ( ) Fracture of Vault of Skull (800) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: frontal bone and parietal bone Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Fracture of Base of Skull (801) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: fossa, sinus, anterior, ethmoid, middle, frontal, posterior, sphenoid bone, occiput bone, temporal bone, and orbital roof Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Other and Unqualified Skull Fractures (803) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: skull NOS and skull multiple NOS Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other unspecified nature July 2015 Page 6

7 Multiple Fractures Involving Skull or Face with Other Bones (804) (Requires fifth digit see chart on page 5 for codes and definitions) Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Intracranial Injury, Excluding Those with Skull Fracture ( ) Concussion (850) Includes: commotion cerebri With no loss of consciousness (concussion with mental confusion or disorientation, without loss of consciousness) With brief loss of consciousness (of consciousness for less than one hour) With moderate loss of consciousness (loss of consciousness for 1-24 hours) With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) With prolonged loss of consciousness, without return to pre-existing conscious level With loss of consciousness of unspecified duration, unspecified Concussion, unspecified Cerebral Laceration and Contusion (851) (Requires fifth digit - see chart on page 5 for codes and definitions) Cortex (cerebral) contusion without mention of open intracranial wound Cortex (cerebral) contusion with open intracranial wound Cortex (cerebral) laceration without mention of open intracranial wound Cortex (cerebral) laceration with open intracranial wound Cerebellar or brain stem contusion without mention of open intracranial wound Cerebellar or brain stem contusion with open intracranial wound Cerebellar or brain stem laceration without mention of open intracranial wound Cerebellar or brain stem laceration with open intracranial wound Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound Other and unspecified cerebral laceration and contusion, with open intracranial wound Subarachnoid, Subdural, and Extradural Hemorrhage Following Injury (852) (Requires fifth digit see chart on page 5 for codes and definitions) July 2015 Page 7

13 Related Condition Diagnostic Code incomplete) Longitudinal deficiency, combined, involving humerus, radius, and ulna (complete or incomplete) Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete) Lowe (-Terrey-MacLachlan) syndrome (oculocerebrorenal dystrophy) Lumbar Malignant neoplasm of the brain 191 Marfan syndrome Meningitis due to unspecified bacterium Metachromatic leukodystrophy Mixed conductive and sensorineural hearing loss Moderate or severe impairment, better eye, profound impairment lesser eye Mucopolysaccharidosis (Hunter s syndrome, Hurler s syndrome, Scheie s syndrome) Multiple sclerosis 340 Multiple sites of spinal cord Myasthenia gravis Myotonic Dystrophy (as of 7/10/2015) Neoplasm of uncertain behavior of endocrine glands and nervous system 237 Neurofibromatosis (von Recklinghausen s Disease) Obstructive hydrocephalus Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with intracranial injury of other and unspecified nature Open with intracranial injury of other and unspecified nature Open with intracranial injury of other and unspecified nature Open with intracranial injury of other unspecified nature Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open without mention of intracranial injury Open without mention of intracranial injury Open without mention of intracranial injury Open without mention of intracranial injury Optic nerve injury (second cranial nerve) Osteogenesis imperfect July 2015 Page 13

16 Related Condition Diagnostic Code Unspecified open wound of ocular adnexa Unspecified site of spinal cord With brief loss of consciousness (of consciousness for less than one hour) With loss of consciousness of unspecified duration With moderate loss of consciousness (loss of consciousness for 1-24 hours) With no loss of consciousness (concussion with mental confusion or disorientation without loss of consciousness) With open intracranial wound With open intracranial wound With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) With prolonged loss of consciousness without return to pre-existing conscious level Without mention of open intracranial wound Without mention of open intracranial wound (cerebral compression due to injury, intracranial hematoma following injury, traumatic cerebral hemorrhage) July 2015 Page 16

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